Humana
This range is provided by Humana. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.
Base pay range $71,100.00/yr - $97,800.00/yr
Become a part of our caring community and help us put health first
The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Coordinate care for MHS beneficiaries receiving care outside the MTF. Monitor quality of care, identify, and document any potential quality issues regarding the patient’s care. Coordinate patient transfers and document appropriately in MSR. Review inpatient outlier cases, ensure appropriate and timely discharge planning, and refer to Tier III care management as needed.
Responsibilities
Perform prior authorization reviews according to established HUMANA GOVERNMENT BUSINESS contractual requirements and guidelines, including timely data entry in MSR.
Perform accurate and timely assessment and concurrent review of outlier admissions using InterQual criteria and document review results in MSR. Pend cases appropriately to second level review and follow up with any denial activities as indicated.
Complete and document in MSR accurate and timely determinations of appropriateness of level of care; take appropriate actions to facilitate direction of patients to correct level of care as indicated by criteria.
Direct discharge planning appropriately; maximize steerage of patients to the MTFs and preferred providers; facilitate move to alternative levels of care in a timely manner.
Identify and follow patients requiring Tier II Care Management. Coordinate cases with and refer to tier III Care Manager and Disease Management Programs as appropriate.
Required Qualifications
U.S. citizenship (Department of Defense Contract requirement).
Successful interim approval for government security clearance (NBIS).
Not authorized to work in Puerto Rico per our government contract; candidates residing in Puerto Rico are not eligible.
Registered Nurse with a current in‑state RN license.
At least 3 years of varied clinical RN nursing experience.
Current TRICARE experience.
Current knowledge of MCG evidence‑based criteria or comparable (e.g., InterQual, etc.).
Preferred Qualifications
Utilization Review/Quality Management experience.
BA/BSN degree.
Work‑At‑Home Requirements
Must provide a high‑speed DSL or cable modem for a home office. Associates or contractors who live and work from home in California will be paid for their internet expense.
Minimum standard speed for optimal performance of 25x10 (download 25 Mbps × upload 10 Mbps) is required.
Satellite and wireless internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.
Travel: While this is a remote position, occasional travel to Humana’s offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full‑time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job‑related skills, knowledge, experience, education, certifications, etc.
$71,100 - $97,800 per year. This job is eligible for a bonus incentive plan based on company and/or individual performance.
Description of Benefits Humana, Inc. and its affiliated subsidiaries offer competitive benefits supporting whole‑person well‑being, including medical, dental and vision coverage, a 401(k) retirement savings plan, paid time off, holidays, volunteer time off and parental, caregiver and disability insurance.
About Us Humana Inc. is committed to putting health first for our teammates, customers and company. Through our Humana insurance and CenterWell services, we aim to help millions of people achieve their best health.
Equal Opportunity Employer Humana does not discriminate against any applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. Humana takes affirmative action to employ individuals with disability or protected veteran status and bases all employment decisions only on valid job requirements.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Health Care Provider
Industry Insurance
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Base pay range $71,100.00/yr - $97,800.00/yr
Become a part of our caring community and help us put health first
The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Coordinate care for MHS beneficiaries receiving care outside the MTF. Monitor quality of care, identify, and document any potential quality issues regarding the patient’s care. Coordinate patient transfers and document appropriately in MSR. Review inpatient outlier cases, ensure appropriate and timely discharge planning, and refer to Tier III care management as needed.
Responsibilities
Perform prior authorization reviews according to established HUMANA GOVERNMENT BUSINESS contractual requirements and guidelines, including timely data entry in MSR.
Perform accurate and timely assessment and concurrent review of outlier admissions using InterQual criteria and document review results in MSR. Pend cases appropriately to second level review and follow up with any denial activities as indicated.
Complete and document in MSR accurate and timely determinations of appropriateness of level of care; take appropriate actions to facilitate direction of patients to correct level of care as indicated by criteria.
Direct discharge planning appropriately; maximize steerage of patients to the MTFs and preferred providers; facilitate move to alternative levels of care in a timely manner.
Identify and follow patients requiring Tier II Care Management. Coordinate cases with and refer to tier III Care Manager and Disease Management Programs as appropriate.
Required Qualifications
U.S. citizenship (Department of Defense Contract requirement).
Successful interim approval for government security clearance (NBIS).
Not authorized to work in Puerto Rico per our government contract; candidates residing in Puerto Rico are not eligible.
Registered Nurse with a current in‑state RN license.
At least 3 years of varied clinical RN nursing experience.
Current TRICARE experience.
Current knowledge of MCG evidence‑based criteria or comparable (e.g., InterQual, etc.).
Preferred Qualifications
Utilization Review/Quality Management experience.
BA/BSN degree.
Work‑At‑Home Requirements
Must provide a high‑speed DSL or cable modem for a home office. Associates or contractors who live and work from home in California will be paid for their internet expense.
Minimum standard speed for optimal performance of 25x10 (download 25 Mbps × upload 10 Mbps) is required.
Satellite and wireless internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.
Travel: While this is a remote position, occasional travel to Humana’s offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full‑time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job‑related skills, knowledge, experience, education, certifications, etc.
$71,100 - $97,800 per year. This job is eligible for a bonus incentive plan based on company and/or individual performance.
Description of Benefits Humana, Inc. and its affiliated subsidiaries offer competitive benefits supporting whole‑person well‑being, including medical, dental and vision coverage, a 401(k) retirement savings plan, paid time off, holidays, volunteer time off and parental, caregiver and disability insurance.
About Us Humana Inc. is committed to putting health first for our teammates, customers and company. Through our Humana insurance and CenterWell services, we aim to help millions of people achieve their best health.
Equal Opportunity Employer Humana does not discriminate against any applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. Humana takes affirmative action to employ individuals with disability or protected veteran status and bases all employment decisions only on valid job requirements.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Health Care Provider
Industry Insurance
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